The Private Provider Duly Authorized Representative Employment Affidavit is a City of Cape Coral Building Division form on which a Private Provider Qualifier affirms that a Duly Authorized Representative is their employee and is entitled to receive unemployment compensation benefits under Chapter 443, as F.S. 553.791 (8) requires. It is a supplemental document for Cape Coral permit work that involves a private provider, completed once for each representative and ending with a notary acknowledgment. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the city publishes the original on capecoral.gov.
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What is Private Provider Duly Authorized Representative Employment Affidavit – Cape Coral, FL?
The Private Provider Duly Authorized Representative Employment Affidavit is a City of Cape Coral Building Division form in which a Private Provider Qualifier affirms that the listed Duly Authorized Representative is the qualifier's employee and is entitled to unemployment compensation benefits under Chapter 443.
The affirmation is made, in the form's own words, "as required by F.S. 553.791 (8)". The page is headed "Supplemental Materials" and carries the City of Cape Coral address at 1015 Cultural Park Blvd, Cape Coral, FL 33990. The footer identifies it as "Private Provider Duly Authorized Rep Affidavit 2-1-2020", a single page.
The form is an employment affidavit, not a permit application: it asks for no property, project or permit information. It identifies one representative by printed name, license number and license type (Standard Plans Examiner or Standard Inspector), and by trade categories. The Private Provider Qualifier then signs, adds a license number and names the Private Provider firm. A notary block for the State of Florida closes the page, with the county, date, the name of the person who appeared, how that person was identified, the notary's signature and a seal.
The form says to use a separate form for each Authorized Representative and to submit a copy of the license for each one.
Who needs to file Private Provider Duly Authorized Representative Employment Affidavit – Cape Coral, FL?
The Private Provider Qualifier completes and signs this affidavit for each Duly Authorized Representative who works for them. The form is written in the first person ("I, ___, the Private Provider Qualifier, do hereby affirm"), so the qualifier is the person who affirms the employment relationship and who appears before the notary.
- One representative per form. The form tells you to list each Authorized Representative individually and to use a separate form for each. A qualifier with several representatives completes several affidavits.
- Licensed representatives. The license line offers Standard Plans Examiner and Standard Inspector, so the representative holds one of those license types, and a copy of the license goes with the affidavit.
- Notary. A Florida notary public completes the acknowledgment at the bottom of the page.
The representative does not sign this form; the signature line is for the Private Provider Qualifier. Do not use it to list several representatives on one sheet. The form does not describe any other use, and it does not replace a permit application.
When to file Private Provider Duly Authorized Representative Employment Affidavit – Cape Coral, FL
Complete the affidavit when a Private Provider Qualifier lists a Duly Authorized Representative, because the affidavit exists to affirm that one representative's employment. Each additional representative needs a new form and a new copy of that person's license. No due date, renewal period or expiration is printed on the form, and the page is marked only as supplemental materials with a revision mark of 2-1-2020. For timing questions tied to a particular project, ask the City of Cape Coral Building Division.
Documents you need
- A copy of the license for each Duly Authorized Representative: the form says to submit one with the affidavit. The license is a Standard Plans Examiner or Standard Inspector license, matching the box marked on the form.
How to fill out Private Provider Duly Authorized Representative Employment Affidavit – Cape Coral, FL
Enter the Private Provider Qualifier's name
In the opening statement ("I, ___, the Private Provider Qualifier"), enter the name of the qualifier who is making the affirmation.
Print the representative's name
Under Duly Authorized Representatives, enter the Print Name of one representative. Use a separate form for each additional representative.
Enter the license number and type
Next to License Number, enter the representative's license number and mark whether it is a Standard Plans Examiner or Standard Inspector license.
List the trade categories
Under Trade Categories, enter the trade categories that apply to this representative.
Prepare the license copy
The form says to submit a copy of the license for each Duly Authorized Representative. Have that copy ready to go with the affidavit.
Sign and identify the firm
The Private Provider Qualifier signs on Signature of Private Provider Qualifier, then enters the License # and the name of the Private Provider firm.
Complete the notary acknowledgment
The notary fills in the county, the day and year, and the name of the person who appeared, marks "personally known" or "procured Identification" with the ID type, then signs and seals.
Review and download the completed PDF
Check that each line matches the representative's license, then download or print the completed PDF from FillingPDF and assemble it with the license copy as described under How to submit.
How to submit Private Provider Duly Authorized Representative Employment Affidavit – Cape Coral, FL
The form prints no submission channel, portal, fee or deadline. Its letterhead shows the City of Cape Coral at 1015 Cultural Park Blvd, Cape Coral, FL 33990, and the page is headed "Supplemental Materials", so it supports other Private Provider paperwork rather than standing alone. Confirm how and where to deliver it with the City of Cape Coral Building Division.
Before you deliver it:
- Have the Private Provider Qualifier sign it and complete the license number and Private Provider firm lines.
- Have the notary complete the acknowledgment block.
- Add a copy of the license for each Duly Authorized Representative, as the form directs.
FillingPDF lets you fill out and download the PDF; submission follows the city's channels.
Common mistakes to avoid
- Listing more than one Duly Authorized Representative on a single affidavit; the form says to use a separate form for each Authorized Representative.
- Leaving out the copy of the license for a Duly Authorized Representative; the form says to submit one for each.
- Not marking the license type (Standard Plans Examiner or Standard Inspector) or leaving Trade Categories blank.
- Leaving the Private Provider Qualifier's signature, License # or Private Provider firm line empty.
- Skipping the notary block: county, date, the name of the person who appeared, the identification type and the notary's signature and seal are all part of the page.
- Marking neither "personally known" nor "procured Identification" in the notary block, or omitting the type of ID when identification was procured.
- Completing the affidavit for someone who is not the qualifier's employee; the sworn statement is that the representative is the qualifier's employee.
Frequently asked questions
What is the Duly Authorized Representative Employment Affidavit?
It is a City of Cape Coral Building Division form in which a Private Provider Qualifier affirms that a Duly Authorized Representative is their employee and is entitled to unemployment compensation benefits under Chapter 443, as required by F.S. 553.791 (8).
Is this affidavit a Cape Coral permit application?
No. It is an employment affidavit marked "Supplemental Materials". It asks for no property, project or permit details; it identifies one representative, the Private Provider Qualifier and the Private Provider firm.
Do I need a separate form for each Duly Authorized Representative?
Yes. The form says to list each Authorized Representative individually and to use a separate form for each one. Each form also needs a copy of that representative's license.
What do I submit with the affidavit?
A copy of the license for each Duly Authorized Representative. The form's license line refers to a Standard Plans Examiner or Standard Inspector license, so attach the copy that matches the type you marked.
Does the affidavit have to be notarized?
The form includes a Florida notary block (State of Florida, county, date, the person who appeared, how that person was identified, the notary's signature and seal). Complete it as part of the affidavit before delivering it.
Who signs the affidavit, the representative or the qualifier?
The Private Provider Qualifier signs, on the line labeled Signature of Private Provider Qualifier, and also enters a License # and the Private Provider firm. The form has no signature line for the representative.
Can I fill out this affidavit online on FillingPDF?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not submit the affidavit to the City of Cape Coral; delivery follows the city's own channels.
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